Table 3.
Medication Error and Event Rates, By Period
| Baseline | Period 1 | Period 2 | Period 3 | P Value | |
|---|---|---|---|---|---|
| Non-missed-dose medication errors (n)*: | 242 | 134 | 132 | 50 | - |
| Non-missed-dose error rate/1,000 pt-days | 142 | 51.2 | 74.0 | 26.6 | 0.0001 |
| Non-missed-dose error rate/admission | 0.64 | 0.27 | 0.28 | 0.11 | 0.0001 |
| Missed-dose medication errors (n): | 288 | 500 | 400 | 617 | - |
| Missed-dose error rate/1,000 pt-days | 169 | 191 | 224 | 329 | 0.0001 |
| Missed-dose error rate/admission | 0.76 | 1.02 | 0.85 | 1.30 | 0.0001 |
| Non-intercepted potential ADEs (n): | 8 | 4 | 1 | 0 | - |
| Non-intercepted potential ADEs/1,000 pt-days | 4.7 | 1.5 | 0.6 | 0 | 0.0006 |
| Intercepted potential ADEs (n): | 27 | 82‡ | 106‡ | 1 | - |
| Intercepted potential ADEs/1,000 pt-days | 15.8 | 31.3 | 59.4 | 0.5 | 0.15 |
| Preventable ADEs (n): | 5 | 15 | 2 | 2 | - |
| Preventable ADE rate/1,000 pt-days | 2.9 | 5.7 | 1.1 | 1.1 | 0.05 |
| Non-intercepted serious medication errors (n)†: | 13 | 19 | 3 | 2 | - |
| Non-intercepted serious medication error rate/1,000 pt-days | 7.6 | 7.3 | 1.7 | 1.1 | 0.0003 |
| Nonpreventable ADEs (n): | 20 | 24 | 17 | 16 | - |
| Nonpreventable ADE rate/1,000 pt-days | 11.7 | 9.2 | 9.5 | 8.5 | 0.33 |
| Total ADEs (n): | 25 | 39 | 19 | 18 | - |
| Total ADE rate/1,000 pt-days |
14.7 |
14.9 |
10.7 |
9.6 |
0.09 |
| Note: Pt-days indicates patient days; ADE, adverse drug event. | |||||
*
Includes the errors associated with potential ADEs and preventable ADEs.
‡
Of the 82 intercepted potential ADEs in period 2, 77 were potassium chloride errors; and in period 3, of the 106 intercepted potential ADEs, 101 were potassium chloride errors. In period 4, these errors were essentially eliminated by revising the potassium chloride ordering screens.
†
Preventable ADEs and non-intercepted potential ADEs combined.